Provider Service Coordinator - HYBRID

Position Summary:
Responsible for identification, investigation, resolution, and response to all provider claims related matters.

Qualifications:
EDUCATIONAL REQUIREMENTS
Associate's Degree in Related Field or One (1) year of experience in healthcare or health insurance in lieu of education

CERTIFICATION & LICENSURE REQUIREMENTS
None Specified

EXPERIENCE REQUIREMENTS
Two (2) years Customer Service

SKILLS AND KNOWLEDGE
Computer skills with experience using PC software applications including word processing, spreadsheets and databases. Must be able to project a professional, pleasant image while interacting with a variety of personalities, both in person and over the phone. The Provider Service Coordinator role requires fast paced decision making and problem solving skills. The position requires significant depth and breadth of knowledge in medical claims billing and processing, provider contracts and insurance benefits. A successful individual will have the ability to collaborate across the organization to provide the highest level of customer service to the Health Alliance provider partners.

Essential Functions:

• 1. For Contracted providers, Intake (via phone, email or portal) , research, resolve and documents all provider issues related to claims adjustments and various payment issues including the following: billing, reimbursement, code review, timely filing, denied claims, EDI for claims not in system, member-initiated complaints related to providers and provider-initiated complaints, provides documentation of executed contract terminology, understands and ensures compliance with contract language and limitations 2. Respond to Claims related matters from providers not contracted with the health plan. These providers include but not limited to, Dentist, chiropractors etc. 3. Cover the Provider call rotation line by answering questions about their contract, network status, claims questions and other inquiries. 4. Responsible for working website and portal access for provider sign-on requests and responding to providers with approval or denial. 5. Researches website errors and reports findings to the Manager of Provider Relations for Tapestry Link and the appropriate vendor for Evicore or Guiding Care/Altruista. 6. Receive, document and evaluate a provider's request to appeal within the corporate established timeframe and criteria (a claims denial)? In addition, responds directly to provider. 7. Informs appropriate Provider Representative or Contract Specialist of any specific issues that should be discussed with providers that require follow-up or contract changes. 8. Responsible for contacting and initiating reimbursement appeals from non-contracted providers whose claims were priced through the First Health Network.9. Responsible for initiating and documenting QPA appeals and escalating to the contract managers if the provider demands remediation as per Federal guidelines. 10. Assists provider offices that request a walkthrough of the provider portal to use the features appropriately.11. Responsible for working large requests from callers for network status of multiple providers

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.